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1 The European Healthcare Fraud and Corruption Network Who we are and what we do Paul Vincke Managing Director EHFCN CMS – RIZIV – 14 January 2013
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The European Healthcare Fraud and Corruption Network
Who we are and what we do
Paul VinckeManaging Director EHFCN
CMS – RIZIV – 14 January 2013
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CONTENT
• About EHFCN
• About Waste, Fraud and Corruption in Healthcare in Europe– The nature– The scale
• How to tackle the problem – Approach– Methods, tools and best practices
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AIM:
To improve European healthcare systems by
reducing losses to fraud , waste and
corruption.
AIM:
To improve European healthcare systems by
reducing losses to fraud , waste and
corruption.
Our objective:
To support our members in their work to be efficient and effective in countering fraud, waste and corruption in healthcare
Key objectives of EHFCN
EU-Lobby Awareness
Policy Research & Development
Think tank
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Best practicesCommon working
standards
Information &Tools Data
Service Center
www.ehfcn.org
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https://healthfraudhub.com
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European Healthcare Fraud & Corruption Network
Workshop
How to combat fraud with analytics?
Brussels, Thursday 3rd March 2011
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Raising Awareness
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Collaborating with EU, Council of Europe & international institutions
- Involved in the recommendation for
good governance in healthcare by
the Council of Europe’s Committee
of Experts on Good Governance
- Partnership with Ecorys to write a
“Study on corruption in healthcare
in Europe” as ordered by the
Europan Commission
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European classification of healthcare systemsHealthcare
Social services
Bismarck Beveridge
Statutory
Voluntary
Payer
Provider
Free choice
Limited choiceIn-kind services
Re-imbursement
Developing countries
Developedcountries
Insurance
Provision
Cost Containment in Healthcare
• Administrative system inefficiencies
• Provider inefficiencies and avoidable error
• Lack of care coordination
• Unwarranted use of services
• Preventable conditions and avoidable care
• Fraud , error and corruption
Eliminating Waste **Healthcare spending that can be reduced without reducing the quality of care
(Thomson Reuters – October 2009)
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The nature of the problem: Provider Fraud
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Inappropriate prescription
Inappropriate billing/
Inappropriate prescriptionInappropriate care
statistics billing rules /
prescription rules
statistics guidelines/EBM
Examples: Healthcare providers
• UK - A GP falsely claimed to be off work sick, whilst continuing to work in a private practice (was sentenced to 12 months imprisonment)
• UK - A Nurse managed to have her whole family paid by an NHS Trust, by defrauding the NHS out of £125,000
• Germany – A gynaecologist was found to have provided pregnancy advice to... 15 year old girls and 80-year old women
• Netherlands: A dentist made claims for treatments which hadnever occured ; he also declared patients’ treatments on other people’s names. Total damage: approximately € 400,000 in falsified claims, covering 4 years. He faces a fine of up to €550.000.
The nature of the problem : Patient Fraud
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Data - / Identity fraud Wrongfully acquiredright to care or to benefits
Case Study – Patient
• France, 2010 : a man was affiliated with several sickness funds
• A 50-year old man was affiliated with a dozen sickness or pension funds,
• He would provide the same records of care simultaneously
• and was reimbursed up to 12 times his healthcare costs.
• Because his health expenditure was real, no fraud had been detected by the national health insurance.
• It is estimated that the suspect may have embezzled up to €450,000 in recent years.
The nature of the problem : Supplier Fraud
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Counterfeit/
Inferior QualityCorruption
Product- andquality rules Procurement rules
Case Studies – Suppliers• Spain - A company delivered cheaper wheelchairs of less performance than
those actually prescribed by the specialist doctors and which were reimbursed by CatSalut, the Catalan Health Service.
• Patients went to the company with a prescription and the orthopaedist supplied them with a wheelchair.
• The reference supplied did not correspond to the reference on the prescription. The wheelchair was of less performance and corresponded to another reference.
• Patients did not know the characteristics of the article prescribed and would not check if the article matched the reference in the prescription.
• Once the patients signed the document confirming they had received -what they believed- the right equipment the orthopaedist invoiced the article to CatSalut and kept the difference.
• This fraudulent act affected almost 200 patients until it was discovered.
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The nature of the problem
Fraudulent practices include:
- Billing for services never provided, often with patients’ participation often for deceased patients
- Misrepresentation of the cost of care
- The intentional provision of unnecessary or inappropriate services
- Hospitals have been found to falsely claim that they have undertaken surgical procedures to attract extra payments
- Abuse of the healthcare system by drug addicted patients
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The nature of the problem
Corruptive practices include:
- Patients bribe doctors to jump the queue
- GP’s receive kickbacks for referrals to specific hospitals , specialists or nursing homes
- Doctors are issuing fictitious health certificates for courts and other authorities
- Patients pay doctors and nurses bribes for “privileged” treatment
- Procedures for the procurement of medical supplies or devices are “altered”
- Doctors participate in “trainings” financed by pharma companies
- Pharma companies “stimulate” of label use and overconsumption
Informal payments in CEE countries
• “Catastrophic” (*) effects on:– Large size families– People living in urban areas– People with low level perceived health– People with certain types of chronic diseases
• Exempted groups still pay for:- Pharmaceuticals- Disposable materials- Orthopedic materials
(*) > 40% of total household expenditure
(source: ASSPRO CEE 2007 project)26
…….. and in Greece
“Fakelaki price list” :
– At state-owned hospitals• To get into surgery: from €100 to €30.000. • To get catapulted up the waiting : from €30 at the very
bottom, maybe to get ahead of some people in the emergency room, to €20,000 at the top end.
– At private hospitals and clinics: • To get into surgery: from €150 to €7,000. • For medical tests from €30 to €500.
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…but in Germany as wellThe well known surgeon Professor Broelsch has been sentenced to three years behind bars. The judges ordered this sentence for the former Chief Doctor at the Essen University Hospital due to instances of bribery, coercion, fraud and tax evasion.
The 65-year-old doctor seems to have, amongst others, persuaded terminally ill cancer patients to make "voluntary" donations to the University Hospital so that they could receive a liver transplant. It has been claimed that between 2002 and 2007 about 40 private patients were forced to pay these “additional fees" in order to be "dealt with promptly" and particularly by the Chief Doctor himself. In total around 200,000 Euros have allegedly been declared as a donation.
According to claims, Broelsch seems to have explained to his patients that he first treated the "rich, then politicians, then privately insured patients, and only then publicly insured patients." 28
Pharma Industry ……Victim ánd Perpetrator ?
• Counterfeit medicine
• Sub-standard medicine
• Prescription drug diversion
• Promotion of off label use
• Overconsumption
• Conflicts of intrest
• Bribery
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The Ultimate Patient Benefit Test
Is the patient receiving the right drug at the right time atthe right cost with the appropriate information ?
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Innovation Marketing
Walking a thin line : From the Blockbuster Strategy…
- Influencing drug prescription behavior of individual providers and hospitals
- “Sponsoring” of scientific experts, opinion leaders, scientific societies, conferences and trainings
- Manipulation of scientific and clinical data
- Disease mongering
- Creating a need for life style drugs
…. - making healthcare more expensive , less effective and affecting the reputation of the industry itself - …
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…. to strategies for change from within the Industryand the Academic and Professional Circles
• Codes of Conduct/Marketing
• Independant external controllers
• Documented transparency as to funding and sponsoring
• Appropriate sanctions
• Integrity Pacts
• Collective action
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The scale of the problem in Europe
Fraud takes a big bite out of funds earmarked for healthcare
– European risk measurement exercises estimate losses between 3% and 10%, or between 30 and 100 billion Euro
– No country nor healthcare system is safeguarded
The scale of the problemFRAUD/ERROR/ ABUSE DETECTED
2010
FRANCE UK NETHERLANDS BELGIUM
Total Healthcare Expenses € 203 bio € 172 bio € 69 bio € 35 bio
Fraud, errorand abuse
Fraud, error and abuse Fraud
Fraud, error and abuse
Total Healthcare [fraud] Detected € 156,3 mio 13,5 mio € 6,2 mio € 11,1 mio
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Estimated losses to healthcare fraud in the USA
The NHCAA estimates that $ 75 billion has been lost in 2011
– Most of which is Medicare and Medicaid fraud– In 2011 $ 4.1 billion has been recovered in healthcare
fraud judgments– Most common types of fraud come from organized crime,
petty thieves or medical professionals trying to steal from the system (high volume, low value)
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Estimated losses to healthcare fraud in South –Africa
The Healthcare Forensic Management Unit estimates that between $ 0.5 and $1 billion has been lost in 2011 to fraud committed by:
- Service providers (41 %)
- Patients (41 %)
- Administrator staff (15 %)
- Brokers (3 %)
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The scale of the problem - corruption
According to World Bank statistics the average of corruption-related losses in European transition countries is 30% of healthcare funds
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What makes fraud control in healthcare difficult and complex ?
“Fraud control is a miserable business”
Malcolm Sparrow
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…..a miserable business
• What you see is never the problem
• Available performance indicators are at best ambiguous; at worst perverse and misleading
• Fraud control competes with production units for resources
• Fraud control is a dynamic game, not a static one
• Investigation (tool) is not control (objective)
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Exacerbating factors in health insurance
• Public and private insurers seen by significant segments of the population as socially acceptable targets for fraud
• Respectability of the healthcare profession
• Absence of clear distinctions between criminal fraud and other forms of abuse
• Absence of measurement of fraud
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ANTI FRAUD/CORRUPTION
CULTUREDETERRENCEPREVENTION
DETECTIONINVESTIGATION
SANCTIONSREDRESS
PROBLEM
STRATEGY
STRUCTURE
ACTION
DELIVERY
THE COMPREHENSIVE APPROACH TO COUNTERING FRAUD AND CORRUPTION
Copyright Jim Gee 2009
LOSS
MEA
SUR
EMEN
T EX
ERC
ISE
1
LOSS
MEA
SUR
EMEN
T EX
ERC
ISE
2
HOW MUCH?
HOW ? WHERE?
ARE MEASURE REDUCE RE-MEASURE
REPORTACT TO REDUCE LOSSES
HOW y datasamplemeline
Obtain sampleReview information and evidenceDetermine fraud and correctness
Mobilise honest majorityDeter dishonest minority
Remove process
E 1 STAGE 2 STAGE 3 STAGE 4
URE, REDUCE AND RE-MEASURE LOSSES
Prevention and detection tools
• Prepayment screening
• Risk assessment
• Business analytics– Anomaly detection: data mining– Predictive models
repayment screening
Health serviceprovider
ent
EPJ Communication-system
KuHL
Service provider
Claim
Case worker
Mon
ey
Healthnet / Internet
CommunicationPlatform
Security Decompression Distribution
PKI-Supplier
Patient
DiskettePaper TSS
TPS
Exemption card
Automaticreimbursement
Rules engine
Processing-unit
Web-GUI
manual reimbursement
KUHR
DatabaseManual procedure
Info
ValidateApprove Decision
Registers
Paymentnk UR
Decision
General Risk Matrix 2011ery high
H igh
M edium
Lo w
Very lo w
Insignif icant M ino r M o derate Signif icant Severe
C O N S E Q U E N C E
critical
high
moderate
low
Risk level
0
1
2
3
4
5
1 2 3 4 5
Types of reimbursement claims
1 = Chemist/Pharmacy8 = Medical prescription (blue)11 = Physioterapy12 = Midwife15 = Chiropractor17 = Medicine, medication & drugs19 = General Practitioners20 = Speech therapists22 = OutPatients/Polyclinic25 = Psychology27 = Dentists……30 = Exemption Card
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11
17
19
27
112
15
20
25
30 22
a Hybrid Approach for Fraud, Waste & Abuse Detection )
P ti l li bi ti f ll 4 h t b id f ilit d t k
Hybrid Approach
Suitable for knownpatterns
Suitable for unknownpatterns
Suitable for complexpatterns
Suitable for associativelink patterns
rs Members
s Claims
Financialsls
rprise Data
3rd Party Data
Rules
Rules to filter fraudulent claims and behaviors
Examples:
• upcoding / correct coding
• Value of charges for procedure exceeds threshold
• Daily provider billing exceeds possible
Anomaly Detection
Detect individual and aggregated abnormal patterns vs. peer groups
Examples:
• Ratio of € / procedure exceed norm
• # procedures / provider exceeds norm
• # patients from outside surrounding area exceeds norm
Predictive Models
Predictive assessment against known fraud cases
Examples:
• Like upcoding behavior as known fraud provider
• Predicted diagnosis does not match actual
• Like provider/network growth rate (velocity)
Social Network Analysis
Knowledge discovery through associative link analysis
Examples:
• Provider association to known fraud
• Linked members with like suspicious behaviors
• Suspicious referrals to linked providers
ractitioner operation analysis 2009Multi-dimensional (example)
Eksempel: Forbruksindex Fysioterapi (Multi-risiko)
0
2
4
6
8Risikoindikator 1 "Refusjonsbeløp"
Risiko indikator 2 "Antallkonsultasjoner"
Risikoindikator 3 "Antall risiko-takster"
Gjennomsnitt for alle behandlere Behandler nr nnnnnnnnnnn
•Therapist has 4 times higher claims than national average
•3 times more consultations per day than national average.
•5 times more risk-treatments than national average
Risk index Physiotherapy (Multi-dimensional)
Risk-indicator 1Total claims (NOK)
Risk indicator 2No. Violations above
critical values
Risk indicator 3No. Consultations
per day (est.)
Average all therapists Therapist nnnnnnnn
harmacy has :more often recurrent bar codes than otherson products with no bar code problems…
nd/ormore often unregistered bar codes…..
eory : Each medicine box has a unique code, registered when the pharmacy sells it If the same bar code appears twice in the billing process, it is an anomaly, possibly due to :
– an error when producing bar codes– an error when scanning it for sale– …or a non-authorized reimbursement
About 2 to 3 % of the bar codes are unregistered during sale
best practice example from Belgian Pharmacies : Unique Bar Codes
mining technique of pharmacies : each nodes is a pharmacy,nk between two pharmacies represents theof bar codes in common.
ar codes are used correctly, all pharmacies areted one to another by a link of about the sameuble bar code randomly spread out).rmacy, for example, creates false bar codes, ite a high 'degree of centrality' in the graph
Pharmacy : Unique Bar Codes
f the initial data base : 250 million linestive : classification of the pharmacies depending on the risk of bar aud
nalytics alone is not the answerrce : Accenture at EHFCN Analytics Workshop 2011)
• Enables understanding, detecting and preventing fraud• Has adaptable solutions to tailor prevention strategies for
different fraud typologies• But it is not enough
The use of Analytics
• Involvement at the highest level is required due to the close links to financial crime and significant cost to both public and private sectors
• Should create a hostile environment to discourage fraudsters
National Counter Fraud Strategy
• Whilst you may be able to achieve plenty on your own, you will achieve more by working together
• Sharing knowledge and intelligence will be key to protect the industry
Collaboration & Cooperation
•The scale of the fraud problem should be communicated and explained to members of your organisations
•Develop a culture of zero tolerance and encourage whistle blowing
Culture & Governance
•The biggest achievements will be made with regulation and Regulatory &
5 Guiding Principles to Fight Fraudin Healthcare (source : NHCAA)
1. The sharing of anti-fraud information between all competent authorities, private and public, should be encouraged and enhanced
2. Data consolidation and real time data analysis must be at the forefront of healthcare fraud detection and prevention
3. Pre-payment reviews and audits should be increased and strengthened
4. Healthcare providers participating in fraud should be sanctioned by their respective licensing boards
5. Investment in innovative healthcare fraud prevention, detection and investigation efforts and programs should be encouraged
Join the fight against fraud and corruption in healthcare
CONTACT EHFCN AT:
OR CALL +32 2 739 7982
www.ehfcn.org
